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Cover Letter
Name of Corresponding Author:Deren Bayram MD
Manuscript Title:AN EMERGENCY CASE; A SUCCESFUL ANESTHETIC MANAGEMENT OF AORTA-TRACHEA FISTULA
Dear Editor-in-Chief, 
On behalf of my co-authors, I am submitting the enclosed material for possible publication . It has not been submitted for publication nor has it been published in whole or in part elsewhere. I attest to the fact that all authors listed on the title page have read the manuscript, attest to the validity and legitimacy of the data and its interpretation, and agree to its submission. All persons listed as authors have contributed to preparing this manuscript, and that no person or persons other than the authors listed have contributed significantly to its preparation. I acknowledge that both I and the other authors have read the Instructions for Authors and agree with its contents.
This report describes 19 year old male with a case with tracheal necrosis and the presence of ascendan aortic fistula with the sign of massive hemoptysis is diagnosed intraoperatively, although preoperative chest CT has not been demonstrated the findings. This is an emergency case report to demonstrate the possible ways of intraoperative management in similar desperate situations.On the first hand, laparotomy is done as planned previously to extract omentum for the support of suspected tracheal injury.  Second part of the operation continued with sternotomy and emergently one lung ventilation and later extra corporal circulation.  At the end of the operation, the patient  transferred to ICU. He has been discharged from hospital without any haemodynamic or neurological complication. In this case priority is maintaining oxygenation. The inflammatory changes in the surgical anatomic region must be carefully considered. Postoperative ventilation parameters and side effects of positive pressure ventilation make ECMO devices mandatory.We believe this case report will help anesthesiologists who participate such conditions in operation theatre.

Deren Bayram, M.D.,
Staff Dr., Department of Anesthesiology and Reanimation, 
Istanbul Florence Nightingale Hospital Istanbul/ TURKEY
Email: deren2003@yahoo.com
Phone: +90 5554991490	
Signature Date: 026, 07, 2017


An Emergency Case; A Succesful Anesthetic Management of Aorta-Trachea Fistula
Deren Bayram1, Alper Toker2, Osman Bay1nd1r3

Titles and affiliations of researchers:
1 M.D., Staff Dr., Department of Anesthesiology and Reanimation, Istanbul Florence Nightingale Hospital, Istanbul /Turkey
2 MD, Prof.Dr.,Thoracic surgery,Istanbul Florence Nightingale Hospital, Istanbul /Turkey
3MD, Prof.Dr.,Department of Anesthesiology and Reanimation, Istanbul Florence Nightingale Hospital, Istanbul /Turkey
Corresponding author: 
Deren Bayram, M.D., Staff Dr., Istanbul Florence Nightingale Hospital
Department of Anesthesiology and Reanimation, Istanbul Florence Nightingale Hospital Abidei Hurriyet Street, No:166 Sisli, Istanbul/ TURKEY
Email:  HYPERLINK "mailto:deren2003@yahoo.com" deren2003@yahoo.com
Phone: +90 5554991490

Reprint Author:
Deren Bayram, M.D., Staff Dr., Istanbul Florence Nightingale Hospital
Department of Anesthesiology and Reanimation, Istanbul Florence Nightingale Hospital Abidei Hurriyet Street, No:166 Sisli, Istanbul/ TURKEY
Email: deren2003@yahoo.com
Phone: +90 5554991490
Financial Support: None
Conflicts: No conflicts of interest

Abstract
This report describes 19 year old male with a case with tracheal necrosis and the presence of ascendan aortic fistula with the sign of massive hemoptysis is diagnosed intraoperatively, although preoperative chest CT has not  demonstrated the findings. This emercency case report to demonstrate the possible ways of intraoperative management in similar desperate situations. On the first hand, laparotomy is done as planned previously to extract omentum  for the support of suspected tracheal injury.  Second part of the operation continued with sternotomy and emergently one lung ventilation and later extra corporal circulation.  At the end of the operation, the patient  transferred to ICU. He has been discharged from hospital without any haemodynamic or neurological complication.In this case priority is maintaining oxygenation. The inflammatory changes in the surgical anatomic region must be carefully considered. Postoperative ventilation parameters and side effects of positive pressure ventilation make ECMO devices mandatory. 
Key Words: Anesthetic Management, Aorta-Trachea Fistula, Tracheal Necrosis, Total Circulatory Arrest, ECMO Device Asistance.








Introduction 
Tracheal stenosis a rare and serious complication of endotracheal intubation1. The treatment should be resection and anastomosis1,2 although this operation carries low risks, once aorta or innominate artery fistula to trachea develops, the situation carry almost %100 mortality rate3,4,5. Chronic inflammation may be a consequence of infections. �Infections are commonly seen nearly in all patients who have stayed in intensive care unit(ICU) for long-term period. Infection of the anastomosis may cause postoperative lethal complications. Tracheal necrosis and aortic fistula is the most lethal condition that could develop in surgical site.  Here in this case report we present a case with tracheal necrosis and the aortic fistula.  We present this case report to demonstrate the possible ways of intraoperative management in similar desperate situations.Tracheal necrosis and the presence of ascendan aortic fistula with the sign of massive hemoptysis is diagnosed intraoperatively. Preoperative chest computed tomography (CT) was unable to demonstrate the findings. Ventilation and oxygenation of the patient intraoperatively has been successfuly managed by anesthesiologist and the surgeons and patient was delivered to ICU safely. We believe this case report will help anesthesiologists who participate such conditions in operation theatre.
Case Report
Our patient was19 year old, 54 kg, 161 cm male with severe midtracheal stenosis and hemoptysis. He scheduled for emergency operation,had no other spesific disease or medical condition when he had a traffic accident at October 2016. He was taken to ICU because of incomplete fracture on the frontal skull. He had an operation due to femur fracture on the 8th day caused by a traffic accident. He has stayed in ICU for15 days.  Tracheostomy prodecure had been performed on the 13th day. After ICU period, stridor has been recognised and a bronchoscopy showed an infection through the cannula hole with purulent secretions. He has developed tracheal stenosis and chronic inflammation. Reconstructionhas been advised by the health center where he has been treated from the beginning. He had severe stridor and mild fever onphysical examination.
He was operated in our hospital two times previously; �first trachea resected and end-to-end anastomosis was achieved, four days later second emergency �operation �was performed because �of a hemoptysis. Left pectoralis major muscle was placed between trachea and vascular tissues to prevent innominate artery to tracheal fistula. As the edema developed four days later in pectoralis major muscle flep, a tracheal stenosis noticed above the anastomosis. Tracheal stent was placed for the treatment of stenosis. Patient was taken to operation room for the third time emergently because of massive hemoptysis with a mild fall in saturation measured by pulse oximetry after chest CT imaging for diagnosis, 4 days later chest CT was unable to demonstrate the severity of the situation.
Patient was breathing spontaneosly in ICU withO�  mask with 6lt/min with tachypnea and hemoptysis, no inotropic support was needed. He had normal NIBP(non-invazive Blood Pressure), ECG  (electrocardiogram) values. Saturation measured by pulse oximeter was %86. He was not taking enteral nutrition. He had enterobacteria infection in the sputum culture.
He has been oxygenated during the transfer from ICU to operation room(OR) monitoring NIBP, pulse oximetry and ECG.Blood pressure and heart rate was in normal range but saturation was %86. During induction�3,5 mg/kg Propofol (Propofol� %1 Fresenius), 2mg midazolam(Dormicum�5mg/5mlRoche), 100�g fentanil (Fentanyl � Johnson&Johnson) and 50 mgrocuronium bromide (Esmeron� 50mg/5ml N.V. Organon) injected. After induction, patient manually ventilated without any difficulty was intubated via C-MAC �D-blade on the first try without any difficulty and a 6mm spiral endotracheal tube was used. Endotracheal aspiration showed previous mild bleeding to lungs. The pressure of the cuff was measured to held the pressure between 22-32 cmH� O. �Mechanical ventilation was set with tidal volume (TV) 450ml, fr 12/min. FiO�  was 100%. Total intravenous anesthesia was used there after. Arterial line has been placed on his left radial artery. There was already a central venous catheter in the right internal jugular vein (8,5F). Body temperature of �the patient was (39.5C 
). We have given 100 mg parasetamol IV. The temperature �of the room has been lowered additionaly as the laparotomy has started. We succeeded in lowering his body temperature to (36.5C�)after 2 hours.
On the first hand omentum has been prepared via laparotomy as planned previously to be used for the support of suspected tracheal injury.  Second part of the operation started with sternotomy. As sternotomy was opened, sudden rupture of the posterior side of the aorta occured. After clemping and dividing the right innominate artery (IA), posterior side of the aortic hole is clemped and it was extending towards the left carotid artery. As the right cerebral perfusion was in danger due to division of the right IA and clamping of the left carotid artery is needed for the repair. We started emergently preparations for cardiopulmonary bypass(CPB). During this time, exploration revealed that the stent that should be inside the trachea could be seen totally, there was not a trachael tissue on the anterior wall, which was necrosed from 2nd tracheal ring up to 4 rings above carina. Capnograph showed no value at that moment, indicating us an unsuccesful mechanical ventilation. �We deflated the cuff and pushed endotracheal tube till the connector is just on the side of the patient�s mouth. Although there was no sign of ventilation we started jet-ventilation. SO�  showened by pulse oximeter started to fall down to 70% two and a half minutes �later during 30sec. Hemodynamic values didn t fall down. Distal end of the tracheal tube has been placed inside right bronchi by thoracic surgeon and the capnograph indicated succesful ventilation. Saturation started to rise and no dysrythmia or lowered blood pressure has been observed during this time. Endotracheal tube has been fixated by surgical method to the right bronchi. We started mechanical ventilation with TV 200 ml fr 30/min,peek inspiratory pressure(PIP) was 33cmH� O.  IA which �has been �seperated from aorta sutured from the proximal edge immediately.IBP was 120/55 mmHg, because of bleeding we gave 1 unit of eritrosit suspension.
Aortic patch was necessarily vital so on the next step CPB was achieved by left femoral venous-arterial way and circulation had managed by heart-lung machine on the third hour with � flow rate. Cardioplegic solution has been given afterwards by antregrad route and asistoli occured. Body temperature lowered to (18C�) for total circulatory arrest. We applied ice around patients s head additionaly to lower cerebral metabolic activity (CMRO� ). Placement of the pericardial patch to aorta on the defect  was completed undertotal circulatory arrest and  body temperature slowly raised with heart-lung machine asistance. Systolic function of the heart returned back spontaneously at (30.5C�). Circulatory support has continued with ECMO device because of disturbed airway integrity, and to have lower TVfor the prevention of the disruption of the tissues from trachea.Treatment of trachea was done with the help of Montgomery T tube, split thicknessskin flep, omentum and pectoralis major muscle reconstruction.For the tracheal treatment, tracheal side was cleared off the infected tissue. We added four units of erythrocyte suspension during CPB and extra corporeal membrane oxygenation (ECMO) period.
Patient has been taken to ICU with ECMO device.  Our attempt to mechanically ventilate the patient during the end of the surgery and the transfer period from OR to ICU resulted with high peak pressure even if we set small TVbecause PIP was 33 cmH� O.Pneumomediastinium was unpreventable so we ended mechanical ventilation. Slow lung recruitment therapy has been left to ICU team and the patient has been extubated on the 5th postoperative day.


Discussion 
Loss of trachea�s anatomic integrity is a rare occasion. In this case chronic infectious and inflammatory changes both affected tracheal anastomosis and the aortic-IAjunction.  Whatever the causes are, our purpose to report this case is to inform anesthetists; about the possibilities of treatment modalities we developed during surgery. We transfered the patient without hemodynamic or neurological complication to ICU. Forthis reason, we believe, the case worth sharing in the literature. What makes the case unique is the loss of integrity between aortic wall and IA junction point,  the achievement of mechanical ventilation with one lung before tracheal reconstruction, clamping of the area before emergent cardiovascular surgery intervention, on the second hand reconstruction of trachea. In this situation what was vitalin terms of anesthesiologist was pushing the endotracheal tube totally to the distal edge of trachea in order to ask for the help of thoracic surgeonin the open mediastinum to place the tube inside right bronchi; and make arrangements for CPB.Gibaud et al. had a similar case7. They had viewed a large aneurysm between the junction of IA and aortic arch with a compression to trachea by CT. Respiratory compromise without pre-operative hemoptysis had been present and there had been no tracheal necrosisas we had. They observed hemoptysis during tracheobronchial aspiration after intubation. In their case after intubation they maintained circulatory support withextra corporal circulation (ECC) by ilioiliacroute before median sternotomy.Imminent intratracheal rupture had been expected in their case. They observed an arteriotracheal fistula above carina and it has been surgically repaired. We maintained circulatory support by CPB after sternotomy by femorofemoral route. In both cases circulatory arrest was mandatory to repair aortic arch. They didn�t need circulatory support after operation had been completed and they were succesful in maintaining mechanical ventilation by endotracheal tube.
We were unable to diagnose this condition with chest CT scanning. Also we did not expect deterioration of  tracheal integrity. Lytic effects of chronic inflammatory changes in the mediastinium on the anastomotic site was unknown due to contemporary diagnostic devices. The point that should be kept in mind is that radiology will not be able to provide definitive images+7;�����	`aQq���Ʊ�Ơw�i�XG9Gh~3OJPJQJnH	tH	 h?3hd�OJPJQJnH	tH	 h?3h/
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�h�X"CJOJPJQJaJ h�b�h� �CJOJPJQJaJ on this issue and hemoptysis can be originated from the arteries which are melted by the infection, as well as keeping the blood and its products ready and  besides this another team for extra corporal circulation should be informed to get ready would help in the success of surgery.
Postoperative ventilation parameters and the side effects of positive pressure ventilation at the surgical area makes ECMO devices imperative6.  Our ventilation attempt at the end of surgery was uneffective. It has been seen in many cases that high pressure levels, limited TV and hypercarbia made ECMO device asistance is the only solution to oxygenate the patient8-14.  
In this case our priority was to maintain oxygenation. About inflammatory changes on the surgical anatomic site should be in caution.Future researchs and developments can be focused on the diagnosis of detecting and figuring out such lytic changes.

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